385600428-8-11-2021-14-AS-KHOS-C69N2C-20210826100432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 08/11/2021
Date Signed: 08/11/2021 02:31:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210503102402

FACILITY NAME:	VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE		FACILITY NUMBER:	385600428
ADMINISTRATOR:	MORALES,CLAUDIA		FACILITY TYPE:	740
ADDRESS:	624 LAGUNA ST		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	56	CENSUS: 39	DATE:	08/11/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Andrew Valesquez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff did not meet resident's hygiene needs

INVESTIGATION FINDINGS:

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On 08/04/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up 10-day complaint inspection visit with Office Manager Andrew Valesquez. LPA reviewed the allegations, explained the purpose of the visit, and then delivered the finding.

Concerning the allegation of facility staff not meeting the resident's hygiene needs, LPA Filouane reviewed image of the resident's nails, which indiciate a period of time without having received nail grooming services. LPA interviewed the Administrator and reviewed the resident's Needs and Services Plan. The Needs and Services Plan includes grooming under Total Assist, with nail trimming and cleaning weekly.

Based on LPA’s observations, record review, and interview, which were conducted along with a file review, the preponderance of evidence has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6 & Chapter number 1) is being cited on the attached LIC 9099D.

Exit interview conducted with the Office Manager. LPA will email the Administrator this signed report.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 14-AS-20210503102402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/11/2021 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.	1 2 3 4 5 6 7	The Licensee shall address the Needs and Services plan of residents in care.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: the Licensee failed to accord healthful and comfortable accommodations to the resident.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210503102402

FACILITY NAME:	VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE		FACILITY NUMBER:	385600428
ADMINISTRATOR:	MORALES,CLAUDIA		FACILITY TYPE:	740
ADDRESS:	624 LAGUNA ST		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	56	CENSUS: 39	DATE:	08/11/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Andrew Velasquez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Lack of supervision, which resulted in resident falling multiple times and sustaining injuries.
Facility failed to notify responsible party of resident's weight loss
Facility failed to notify responsible party of incidents
Insufficient staffing
Staff failed to safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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On 08/04/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up 10-day complaint inspection visit with Office Manager Andrew. LPA reviewed the allegations, explained the purpose of the visit, and then delivered the findings.

Concerning the allegation of facility lacking supervision, which resulted in the resident falling multiple times and sustaining injuries, LPA Filouane interviewed the Administrator, reviewed the facility staffing schedule records, reviewed the facility service plan evaluation, and reviewed incident reports submitted to the Community Care Licensing Division. The facility service plan evaluation included a conference with the responsible party. The facility reported the resident's change in behavior could mean the resident's diagnosis could be progressing. According to the service plan evaluation, the facility suggested a higher level of care for the resident at the time due to behavior changes. After review, this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20210503102402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 08/11/2021

NARRATIVE

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Concerning the allegation of facility failing to notify responsible party of resident's weight loss, LPA interviewed a previous facility director and a current facility director, as well as requested a Weight Check Record. The document indicates a weight loss occurred in the year of 2019. Record reveals that Sutter Health was informed of the previous resident's weight loss. After review, this allegation is unsubstantiated.

Concerning the allegation of facility failing to notify responsible party of incidents, LPA interviewed the previous facility director and current facility director, as well as requested Incident Reports from the facility. According to Title 22, the facility submitted the required Incident Reports to the Community Care Licensing Division (CCLD) regarding the resident in question. After review, this allegation is unsubstantiated.

Concerning the allegation of facility having insufficient staffing, LPA interviewed the previous facility director, current facility director, as well as reviewed the facility's staffing schedule. Incident reports submitted to CCLD report that the resident in question had unwitnessed falls. In a care conference with facility staff and Sutter Hospice, the responsible party was made aware the resident in question had been wandering/attempting to get up unassisted. After review, this allegation is unsubstantiated.

Concerning the allegation of facility staff failing to safeguard resident's personal belongings, the LPA interviewed the previous facility director, current facility director, and reviewed the resident's personal property and valuables chart. There is not a preponderance of evidence to prove the alleged violation did or did not occur. After review, this allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with the Office Manager. The facility director will receive a copy of this report through email.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC9099 (FAS) - (06/04)

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